Inspection·December 3, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few assessments for the other residents during her shift. RN E stated she believed there was new breakdown on Resident #1's heels. RN E stated that she was unsure if there were orders in place for Resident #1. RN E stated that she was unable to log into the facility computer on 11/30/2025 and unable to access the resident's charts. RN E stated that she reported the breakdown to RN B, who was the charge nurse this day, and did not report it to the DON/ADON/NP or MD. RN E stated since she did not have access to the computer or charting system she did not finish skin assessments and did not document the assessments she did complete anywhere. RN E stated she only completed a handful of skin assessments and did not complete any other assessments because she was unable to get into the charting system and was busy during her shift. During an interview on 12/02/2025 at 2:01 PM, CNA C stated that he provided care for Resident #1. CNA C stated that he recalled seeing blistering on Resident #1's right heel. CNA C stated sometimes when he arrived for his shift ( 6:00 am to 2:00 PM) he saw brown spots on Resident #1's sock or sheets from his heel. CNA C stated that he reported the change in Resident #1's heel to RN A the second day Resident #1 was at the facility. CNA C stated he was instructed to place a boot on Resident #1's foot, but he was not sure who instructed him to do so. CNA C stated he felt the area on Resident #1's heel was not smaller in size. CNA C stated any changes in skin are reported to the charge nurse and documented on the POC. During an interview on 12/02/2025 at 2:01 PM, CNA D stated that Resident #1 had a sore on his heel, but it looked better. CNA D stated the nurse put a bandage on Resident #1's heel sometimes and that a pillow was kept under his heel. CNA D stated that any changes in skin were reported to the charge nurse. During an interview on 12/02/2025 at 2:05 PM, RN A stated that RN B completed Resident #1's admission and that he was asked by RN B to complete Resident #1's admission skin assessment a few days after Resident #1 admitted . RN A stated that he was not sure if Resident #1 was seen by a wound care doctor. RN B stated when skin issues were found upon admission orders were supposed to be put in to treat the wound and to follow up with wound care. RN A stated that Resident #1 had an abrasion on his heel that was a blister and it was still there. RN A stated that usually blisters were reported to the wound care doctor. He stated that he did not report it because RN A did the admission and he only helped by completing the skin assessment. A telephone interview was attempted with RN B on 12/02/2025 at 3:34 PM a voicemail requesting a return phone call was left. No phone call was returned. During an interview on 12/03/2025 at 9:57 AM, RN A stated that Resident #1's heel was as [RN A] described in my notes. RN A stated that Resident #1 had an abrasion on his heel. RN A described Resident #1's heel as open. RN A stated he did not recall any orders for treatment related to Resident #1's heel. RN A stated that Resident #1 was not admitted during his shift and that Resident #1 had been at the facility for a few days when he completed Resident #1's admission skin assessment. RN A stated that he saw Resident #1'sheel on 12/2/2025 and 12/1/2025 during his shifts and described it as about the same. RN A stated that there should have been an order for treatment of Resident #1's heel. RN A stated that after he completed Resident #1's skin assessment he did not call the NP or doctor. RN A stated that the facility did not have a DON or ADON during the assessment or as of 12/3/2025. RN A viewed a picture of Resident #1's heel dated 12/3/2025 with a time stamp of 9:36 Am. RN A stated that he did not stage Resident #1's heel as it was only an abrasion. RN A stated that it looked like a pressure sore in the picture. RN A stated that if a pressure sore is not addressed it can get worse. RN A stated there was an area above Resident #1's heel that was dark and looked necrotic (relating to or characterized by the death of cells in an organ or tissue due to disease, injury, or failure of the blood supply). RN A stated that he did not recall that dark spot above Resident #1's heel at admission. RN A stated he was not sure what was being done to address Resident #1's heel since there were not orders. RN A stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few was a wound doctor that came to the facility but was not sure who the company was as the facility was recently acquired by a new company. During an interview on 12/03/2025 at 1:18 PM, CNA F stated that if she found a change in skin such as a bruise or anything that was not there before, she would report to the charge nurse immediately. CNA F stated it was important to report to the nurse because it could be a result from a fall or something else. CNA F stated she was not familiar with Resident #1. During an interview on 12/03/2025 at 1:27 PM, RN G stated when skin issues are reported the first thing she would do is assess the resident. RN G stated if it was a known skin issue she would look to see if it has was worse or better and if there was any pain. RN G stated that she viewed Resident #1's heel today (12/03/2025) and stated that it looked like a pressure ulcer was starting on Resident #1's heel. She stated that it did not look like an abrasion. RN G stated an abrasion was surface level scratched and that it looked like a pressure ulcer because of the location. RN G stated Resident #1' had a soft boot to wear but he did not always want to wear it. RN G stated a pillow was put under Resident #1's heel when he was in his wheelchair. RN G stated when she arrived for her shift (6:00 am to 2:00 pm) Resident #1 had pillows under his heels when he was in bed to offload pressure. RN G stated any change in skin was supposed to be reported to the ADM since there was no DON at the facility. RN G stated she could also report changes to the RNC. RN G stated it was important to report changes in the skin because it could increase in size and was important to address before it got worse. RN G stated Resident #1's pressure ulcer on his heel was the size of a nickel and had no depth or odor when she viewed it. RN G stated there was a smaller area above Resident #1's heel that looked as if another pressure ulcer was starting. She stated that it looked black in color and it has not always been like that, but was unsure when it started. She stated that based on the color it looked like eschar (thick, black, scab of dead tissue that forms over deep wound, burn or ulcer). RN G stated there was no drainage and did not think that it was like that when she worked on 11/29/2025 and looked like it was worse. RN G stated Resident #1 should have been seen by the wound doctor. RN G stated skin changes or concerns should also be reported to the NP or doctor. During a subsequent interview on 12/3/2025 at 1:58 PM, RN A stated he did not recall CNA C reported anything to him about Resident #1's heel prior to the skin assessment he did. During an interview on 12/03/2025 at 2:23 PM, RNC stated when there was a change in resident's skin staff should notify the DON or management nurse. RNC stated since there was no DON at the facility staff should notify the ADM who would then call the RNC. RNC stated the NP or doctor should be notified as well. RNC stated it was not acceptable to notify another nurse on duty and leave it at that. RNC stated if staff could not access the charting system they should have contacted the ADM or RNC or anyone in corporate. RNC stated that staff should have still conducted a skin assessment despite not being able to access the resident's chart. RNC viewed a picture of Resident #1's heel dated 12/3/2025 with a time stamp of 9:36 AM. RNC stated that he had not viewed Resident #1's heel in person. He stated that from the look of the picture he would describe the heel as an abrasion and the spot above the heel as a black spot that looked like a scab or looked as if Resident #1 had rubbed his heel on something like the bed. RNC stated an abrasion is from rubbing a sheet and a pressure ulcer was from constant pressure that blocked circulation and caused skin breakdown. RNC stated if there was an order for a wound consult the facility would schedule an appointment at a wound click or the wound physician (that comes into the facility weekly) could have seen the resident. RNC stated the wound care team should have been notified right away. RNC stated no staff reported anything to him about Resident #1's heel and that it should have been reported to the RNC or physician. RNC stated it was important to be reported so it could be addressed and that he expected the physician would have put a treatment order in. RNC stated if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #1's heel was compromised and was not treated it could have had a negative impact on Resident #1's health and could have gotten worse. RNC stated that if a resident admitted with skin issues he expected at least weekly monitoring to occur and to be documented. RNC stated that a skin assessment should have been completed at the time of admission not days later. RNC stated that skin assessments were scheduled for Saturday and Sunday and divided between the two weekend supervisors, but that he recently moved the assessments to be completed during the week. RNC stated a skin assessment should have occurred at least every 7 days for all residents. RNC stated an assessment should be completed up on admission to see if a resident admitted with a wound or not. During an interview on 12/3/2024 at 3:06 PM, the ADM stated she has been at the facility since 11/3/2025 and there was not currently a DON. The ADM stated that any change of condition for a resident (including skin) should be reported to the DON or charge nurse and be charted to discuss in the clinical meeting. An interview was attempted with the MD's office on 12/03/2025 at 3:28 PM, a voicemail was left requesting a return phone call with no return phone call received. Review of facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 2001 reflected the nurse should document full assessment of a pressure ulcer including location, stage, length, width, depth and presence of necrotic tissue. The staff will examine the skin of a new admission of ulcerations or altercations in skin. The physician or designee will authorize orders related to wound treatments and interventions related to wound management. The physician or designee will monitor and document the progress of wound healing. Event ID: Facility ID: 676486 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse of at least 8 consecutive hours a day, 7 days a week for 2 of 14 days reviewed (11/27/2025 and 11/28/2025) reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on duty on 11/27/2025 and 11/28/2025. This failure could place residents at risk of missed nursing assessments, interventions, care and treatment. Findings included: Review of November 2025 nurses schedule reflected zero hours worked by an RN on 11/27/2025 and 11/28/2025. Review of time sheets and scheduled reflected LVN H worked 11/26/2025 from 5:50 PM until 11/27/2027 at 6:54 PM (25 hours). Review of time sheet reflected LVN J relieved LVN H at 6:52 PM on 11/27/2025 and left the shift at 12:38 PM on 11/28/25. Further review of scheduled reflected LVN I worked on 11/28/2025 from 6:00 am to 6:00 pm and was relieved by LVN K who worked from 6:05 pm on 11/28/2025 to 6:47 AM on 11/29/2025. During an interview on 12/02/2025 at 11:42 AM, LVN H stated that she worked 25 hours straight from 11/27/2025 to 11/28/2025. LVN H stated that she was scheduled to work 11/26/2025 to 11/27/2026 from 6:00 pm to 6:00 am. She stated the morning of 11/27/2026 at 4:00 AM (two hours before her shift was scheduled to end) LVN I called in with a family emergency. LVN H stated that the staffing coordinator (CNA D) was on the shift with her and she called other staff to come in to relive LVN H. LVN H stated she was told at 10:37 AM on 11/27/2025 that RNC was going to relieve her but that she was then told at 1:00 pm on 11/27/2025 that RNC was not in the area to relieve her. RNC stated that no one showed up to relieve her until 11/27/2025 at 6:15 PM which was LVN J. LVN H stated that she had to step out twice because she was in tears and felt she did not feel comfortable to pass medication after 16 hours due to being tired and stated she was not sure medications were on time. During an interview on 12/02/2025 at 12:57 PM, CNA D stated she was the staffing coordinator and scheduled staff. She stated that call-ins go through her and the former DON used to handle nursing call-ins. She stated that for any call-ins she sends out a message in the group chat and asks if any nurses are available to pick up a shift. CNA D stated that LVN L never called in but she had a family emergency and called in early morning on 11/27/2025. CNA D stated that RN M was scheduled to work on 11/27/2025 with LVN L, but she called in after she found out LVN L would not be working. CNA D stated that RN M stated she would not come in if there was not going to be a nurse working the floor. CNA D stated when she received word from RN M that she was not going to come in she reached out to the ADM and RNC. CNA D stated she worked from 11/26/2025 at 10:00 pm to 11/27/2025 at 6:00 AM as a CNA. CNA D stated the facility tried to hire more nurses and they just hired RN G. CNA D stated that the LVN J relieved LVN H on 11/27/2025 and LVN I received LVN J on 11/28/2025 both of whom are agency staff. During an interview on 12/03/2025 at 12:30 PM, RN M stated that she was scheduled to work on 11/27/2025 and did not come to the facility because she did not feel safe. RN M stated that on 11/27/2025 at 2:00 AM LVN L called in due to a family emergency. RN M stated that she did not feel comfortable passing medications and had never passed medications to the residents at the facility and did not feel comfortable taking responsibility for 31 residents with 2 CNAs working. RN M stated she was a registered nurse and retired nurse practitioner and she has given medication before. RN M stated she normally worked as a weekend RN supervisor on Saturdays. During an interview on 12/03/2025 at 2:23 PM, RNC stated that he was not aware of an ongoing issue with no RNs being at the facility. RNC stated that the facility was supposed to have at least one RN working 8 consecutive hours and the facility should schedule an RN even if they have to get agency staff or ask the weekend RN supervisor to come in. RNC stated that he has interviewed DON candidates on 12/2/2025 and 12/3/2025. RNC stated DON position is posted on job sites. RNC stated that residents were not admitted to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that required treatment only an RN could provide. RNC stated that he was made aware that LVN L called in at 4:30 AM on 11/27/2025 and that the other scheduled nurse (RN M) decided she was not going to come into work. RNC stated that there were originally two nurses (LVN L and RN M) scheduled to work on 11/27/2025. RNC stated that CNA D handled staffing. RNC stated he was not sure why RN M did not come to work. RNC stated he expected RN supervisors to help with whatever was needed during their shifts and to pass medications if needed. RNC stated efforts were made to relieve LVN H. RNC stated that the maximum amount of hours a nurse could work the floor was 20 hours. RNC stated that a potential risk to working longer than 20 hours was that the nurse may not be as alert working so long. During an interview on 12/03/2025 at 3:06 PM, the ADM stated that LVN H worked the night of 11/26/2025 and started at 6:00 PM and was scheduled to work until 6:00 am on 11/27/2025. The ADM stated on 11/27/2025 LVN L and RN M were scheduled to work. The ADM stated when RN M discovered LVN L was not going to work, RN M decided not to how up because she did not want to be the only nurse. The ADM stated when she found out there were no nurses to relieve LVN H she contacted corporate. The ADM stated that prior to 11/27/2025 staffing had been in place as it was a directive for the facility not to utilize agency staff. The ADM stated the maximum amount of hours staff were supposed to work was 16 hours. The ADM stated the risk for working longer is exhaustion, increased error rates and late medications. The ADM stated that a registered nurse was required to work 8 hours a day. Review of facility policy titled Staffing, Sufficient and Competent Nursing with revision date of August 2022 reflected a registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week. Event ID: Facility ID: 676486 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 3 of 4 (Resident #1, Resident #2, and Resident #3) reviewed for pharmacy services. The facility failed to ensure that all of Resident #1's, Resident #2's, and Resident #3's medications were administered on time as indicated by physician's orders on 11/27/2026. These failures could place residents at risk of exacerbation and/or deterioration of their health conditions, and delayed relief or treatment of symptoms which could result in decreased quality of life, discomfort or hospitalization. Findings included: Review of Resident #1 face sheet dated 12/02/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified fracture of right femur (break in thigh bone), depression (mental health disorder characterized by persistent feelings of sadness), chronic embolism and thrombosis of unspecified deep veins (blood clots in deep veins that cause ongoing circulation problems), and restlessness and agitation. Review of Resident #1 physician orders reflected an order dated 11/15/2025 for Divalproex Sodium Oral Capsule Delayed Release 125 MG with instructions to give 2 capsules by mouth every morning and at bedtime. Review also reflected an order dated 11/15/2025 for Sacubitril-Valsartan Oral tablet 24-26 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review of Resident #1's MAR reflected Divalproex was scheduled for 7:00 am and 7:00 PM. Review reflected LVN H administered Resident #1's first dose of Divalproex on 11/27/2025. Review also reflected Sacubitril-valsartan was scheduled for 7:00 AM and 7:00 PM. Review reflected LVN H administered Resident #1's first dose of Sacubitril-valsartan on 11/27/2025. Review of Resident #1's medication admin audit report reflected on 11/27/2025 LVN H administered Resident #1's Divalproex at 9:25 AM, two hours and twenty five minutes after scheduled administration time of 7:00 AM. Further review of the medication admin audit report reflected on 11/27/2025, LVN H administered Resident #1's Sacubitril-valsartan at 9:35 AM, two hours and thirty-five minutes after the scheduled administration time of 7:00 AM. Review of Resident #1 admission MDS dated [DATE] reflected a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #2's face sheet dated 12/02/2025 reflected a [AGE] year old woman admitted on [DATE] with diagnoses of immobility syndrome (paraplegic), hypokalemia (condition where blood potassium levels are too low and impact muscles, nerves, heart and kidneys), major depressive disorder (serious mood disorder causing persistent sadness and loss of interest that impacts daily life), and other chronic pain (persistent pain not tied to specific injuries). Review of Resident #2's physician orders reflected an order dated 11/19/2025 for Aspirin Oral tablet Chewable 81 MG with instructions to give by mouth every morning and bedtime. Review reflected an order with a start date of 11/19/2025 for baclofen Oral tablet 10 MG with instructions to give by mouth three times a day. Review reflected an order with a start date of 11/19/2025 for buspirone HCL Oral Tablet 5 MG with instructions to give 2 tablets by mouth every morning and at bedtime. Further review reflected an order dated 11/19/2025 for Potassium Chloride ER Oral tablet Extended Release 10 MEQ with instructions to give 2 tablets by mouth two times a day. Review of Resident #2's MAR reflected Aspirin was scheduled for 7:00 AM and 7:00 PM. Review reflected LVN H administered Resident #2's first dose of Aspirin on 11/27/2025. Review reflected Resident #2's buspirone was scheduled for 7:00 am and 7:00 pm and the first dose was administered by LVN H on 11/27/2025. Review reflected Resident #2's Baclofen was scheduled for 6:00 am, 11:00 am and 7:00 pm. Review reflected LVN H administered Resident #2's first and second dose of Baclofen on 11/27/2025. Review reflected Resident #2's Potassium was scheduled to be administered at 7:00 am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and 7:00 pm. Review reflected LVN H administered Resident #2's first dose on 11/27/2025.Review of Resident #2's medication audit report reflected on 11/27/2025 LVN H administered Resident #2's 6:00 Am dose of Baclofen at 10:43 AM, four hours and forty-three minutes after scheduled administration time. Review reflected LVN H administered Resident #2's 7:00 am dose of aspirin at 10:42 AM, three hours and forty-two minutes after the scheduled administration time on 11/27/2025. Review reflected on 11/27/2025 LVN H administered Resident #2's 7:00 AM dose of buspirone at 10:43 AM, three hours and forty-three minutes after scheduled administration time. Review reflected on 11/27/2025, LVN H administered Resident #2's 7:00 AM dose of Potassium at 10:43 AM, three hours and forty-three minutes after scheduled administration time. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS of 15, which indicated cognitively intact. Review of Resident #2's care plan dated 05/29/2025 reflected Resident #2 was on anticoagulants with goal to take anticoagulant as ordered and interventions to administer medication per MD order. Review of Resident #3's face sheet dated 12/3/2025 reflected a [AGE] year old male admitted on [DATE] with diagnosis of Alzheimer's disease (progressive brain disorder leading to gradual memory loss and difficulty thinking), and gastro-esophageal reflux disease without esophagitis (chronic digestive condition where stomach acid frequently flows back into the esophagus). Review of Resident #3's physician orders reflected an order dated 11/25/2025 for Donepezil HCL Oral Tablet 10 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review reflected an order dated 11/25/2025 for Pantoprazole Sodium Oral Tabley Delayed release 40 MG with instructions to give 1 tablet by mouth every morning and at bedtime. Review of resident #3's MAR reflected Donepezil was scheduled for 7:00 Am and 7:00 PM, review reflected LVN H administered Resident #3's first dose of Donepezil on 11/27/2025. Review reflected Resident #3's Pantoprazole was scheduled for 7:00 am and 7:00 PM. Review reflected LVN H administer Resident #3's first dose of Pantoprazole on 11/27/2025. Review of Resident #3's medication audit report reflected on 11/27/2025, LVN H administered Resident #3's 7:00 am dose of Pantoprazole at 10:12 AM, three hours and twelve minutes after scheduled administration. Review reflected on 11/27/2025, LVN H administered Resident #3's 7:00 AM dose of Donepezil at 10:12 AM, three hours and twelve minutes after scheduled administration time. Review of Resident #3's unspecified MDS dated [DATE] reflected BIMS was not completed and Resident #3 had short term memory problems. During an interview on 12/02/2025 at 11:42 AM, LVN H stated that she worked 25 hours straight from 11/26/2025 through 11/27/2025. She stated that she worked from 6:00 pm on 11/26/2026 until almost 7:00 pm on 11/27/2025. LVN H stated that the oncoming nurse called in on 11/27/2025 due to family emergency. LVN H stated that the ADM and staffing coordinator attempted to find coverage. LVN H stated that she had to step out twice and that she was in tears because she was overwhelmed. LVN H stated she texted the ADM that she did not feel competent taking care of the residents and safe passing out medications due to lack of sleep. LVH H stated after working 16 hours she did not feel comfortable passing out medications. She stated that she did not believe there were any missed medications, but she was also not sure if medications were on time because she was so tired on 11/27/2025. During an interview on 12/03/2023 at 1:27 PM, RN G stated that medication had to be passed on her shift (6:00 am to 6:00 PM) between 7:00 am and 10:00 Am. RN G stated if medication was scheduled at 7:00 am, it could be administered an hour prior or an hour after 7:00 AM. RN G stated after the hour mark, it was considered late. During an interview on 12/03/2025 at 1:58 PM, RN A stated medication could be passed 30 minutes to an hour prior to scheduled time. RN A stated if a medication was scheduled for 7:00 am after 8:00 am it was considered late. RN A stated it was important to administer medications on time to ensure noon medications or other subsequent medications did not overlap. During an interview on 12/03/2025 at 2:23 PM, RNC stated the facility was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676486 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676486 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Johnson City 206 Haley Rd. Johnson City, TX 78636 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete a liberalized medication administration timeframe (staff could administer between 7:00 AM through 11:00 AM for medications unless order says otherwise), but some medications had specific time to be administered. RNC stated if specified, there was an hour before and hour after that the medication could be administered. During an interview on 12/03/2025 at 3:06 PM, the ADM stated that she was not aware of the time frames for medication administration. An interview was attempted with the MD's office on 12/03/2025 at 3:28 PM, a voicemail was left requesting a return phone call with no return phone call received. Review of facility policy titled Administering Medications with revision date of April 2019, reflected medications are administered in a safe and timely manners, and as prescribed and staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Review also reflected medication administration times are determined by resident need and benefits which includes optimal therapeutic benefit, prevention medication or food interaction and resident preference. Medications are administered within one (1) hour of their prescribed time. Event ID: Facility ID: 676486 If continuation sheet Page 9 of 9